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37: Inpatient Use of Erythropoiesis Stimulating Agents (ESA) Among Commercially-Insured Dialysis Patients
NKF 2008 Spring Clinical Meetings Abstracts
A37
37
39
% of Hospitalizations
INPATIENT USE OF ERYTHROPOIESIS STIMULATING AGENTS (ESA) AMONG COMMERCIALLY-INSURED DIALYSIS PATIENTS 1Donald Brophy, 2Carolyn Harley, 2Benjamin Chastek, 3 Gregory Daniel, 3Brian McNeeley, 4Matthew Gitlin, 4Tracy J Mayne. 1 Virginia Commonwealth Univ, Richmond, VA; 2i3 Innovus, Eden Prairie, MN; 3HealthCore, Inc, Wilmington, DE, 4Amgen Inc., Thousand Oaks, CA. There is evidence that dialysis patients return from hospitalizations with low hemoglobin levels (Yaqub, 2001; Turenne 2007). Dialysis patients receive outpatient ESAs and one possible factor may be that patients do not receive ESA therapy during hospitalization. This study descriptively evaluates inpatient ESA use from 2004 - 2005 among privately insured dialysis patients. This was a cross-sectional retrospective analysis of claims from two large US managed care organizations (MCO) covering a combined 20 million lives over two years. ESRD patients were identified by ≥1 ESRDspecific claim in the inpatient setting, or ≥3 dialysis-related claims on separate days during each 12-month period. We examined patient demographics and hospitalization characteristics, including the percent of patients receiving ESAs during hospitalization by length of stay (LOS). Patient demographics were similar across years and MCOs. The mean (+SD) number of hospitalizations over both years were ~1.1 (+1.3) for MCO#1 and ~1.6 (+ 1.7) for MCO#2. Table 1:% of hospitalizations with ESA use by LOS 40% 30% 20% 10% 0%
MCO #2 MCO #1 (Averaged across both years)
≤7
8-14 15 – 21 > 21 Length of Stay (days) As shown, ESA use was low, but increased with LOS. Given the low rate of ESA use, patients may be at risk for falling Hb levels during and post hospitalization discharge. Further analysis is warranted to investigate factors associated with ESA use and non-use in the inpatient setting.
38
TESTICULAR ANGINA ON DIALYSIS: A NOVEL PRESENTATION WHILE ESTA BLISHING DRY WEIGHT, Buffington, Mary; Sequeira, Adrian; Isaac, Prasanna; Bahta, Elias Establishment of dry weight is limited by the development of cramps or hypotension during dialysis. We present a case of testicular angina that developed while trying to attain dry weight. The patient is a 68 year old male with hypertension, type two diabetes mellitus and end-stage renal disease on hemodialysis. His surgical history is significant for ischemic colitis with sigmoid resection and abdominal aortic aneurysm repair. He presented initially with volume overload and while attempting to readjust his dry weight on dialysis, he complained of testicular pain occurring peculiarly toward the end of his dialysis session. A few months earlier, he was treated for possible epididymitis and although his symptoms had initially improved with antibiotics they recurred over the last month. He denied any history of sexually transmitted diseases. On examination, he had atrophic and very tender testes particularly on the right although externally the scrotum appeared normal. No swelling, hydrocele, or prostatic tenderness was noted. A CAT scan revealed severe atherosclerotic disease involving nearly every vessel of the pelvis including the spermatic cord vessels. Doppler evaluation and color-flow analysis then showed no flow to either testicle. He underwent bilateral simple orchiectomy for testicular angina with testicular atrophy. Pathology of the resected testes showed extensive atrophy with fibrous parenchyma suggestive of chronic ischemia with evidence of chronic epididymitis. The two commonest mechanisms involved with scrotal pain include decreased blood supply and infection. In a unique presentation, the patient had testicular angina toward the end of dialysis when his blood pressure and intravascular volume were relatively low. This may have aggravated the underlying ischemia. It is believed that the chronic ischemia may have predisposed to a smoldering epididymitis.
40
CALCIFIC UREMIC ARTERIOLOPATHY (CUA) SUCCESSFULLY TREATED WITH INTRAVENOUS SODIUM THIOSULPHATE 1
2
3
Ion D Bucaloiu MD , Evan Norfold MD , Nektarios Lountzis MD , Fred O Miller MD3, Dirk Elston MD3. 1 Department of Internal Medicine, Geisinger Medical Center, Danville, PA. 2 Department of Nephrology, Geisinger Medical Center, Danville, PA. 3 Department of Dermatology, Geisinger Medical Center, Danville, PA.
A 45-year-old African American female with end stage renal disease on chronic peritoneal dialysis developed painful indurated plaques on her buttocks and breasts with subsequent ulceration. Skin biopsy revealed focal intralobular subcutaneous capillary microvascular thrombosis with focal acute inflammation, and rare subtle foci of staining with a von Kossa stain, suspicious for calciphylaxis. Laboratory data revealed a serum calcium and phosphorus product of 45 and a parathyroid hormone level of 581 pg/mL. Despite treatment with cinacalcet and ongoing wound care her secondary hyperparathyroidism and wounds continued to worsen. A subtotal parathyroidectomy significantly improved her PTH levels (886 pg/mL to 107 pg/mL), but her wounds continued to progress and her clinical course was complicated by several episodes of hypocalcemia and bacterial superinfection requiring hospital admission for intravenous calcium and antibiotics. Treatment with intravenous sodium thiosulphate three times weekly was initiated with a dramatic response. Pain resolved after three to four days. Ulcers on the buttocks had healed completely after 6 weeks and those of the breasts were approximately 60% healed (figures). CUA is a severe disease resulting in necrosis of the skin and subcutaneous tissue, leading to extensive wounds, severe pain and high mortality. This case highlights and expands on the mounting evidence of intravenous sodium thiosulphate as a successful treatment for calciphylaxis.
Relationship of calcium intake with serum calcium level. Ms. Fiona Byrne, Dr Sinead Kinsella and Dr JA Eustace. Cork University Hospital, Cork, Ireland We conducted the following prospective observational study on 42 (25 male, 17 female) stable, non-diabetic maintenance hemodialysis patients (pts) to quantify the relationship of oral calcium intake with serum calcium levels. Subjects kept a detailed food diary for 1 week followed by a detailed interview with an experienced renal dietician. Nutrient intake was calculated using WISP v2.0 (Tinuviel Software) Albumin adjusted serum calcium levels were measured pre dialysis on days 1 and 7. Mean (sd) serum albumin, day 7 uncorrected serum calcium (S. Ca), and day 7 albumin corrected serum calcium (S.Ca ALB COR ) were: 35.7 g/dl (2.9), 2.37 mmol/l (0.21) and 2.46 mmol/L (0.2). The day 1 and day 7 serum calcium levels were very similar (mean difference 0.004 mmol/l). S.Ca ALB COR was low (<2.1 mmol/l) in 2 pts, normal (2.1-2.37) in 9 pts, high normal (2.37-2.54) in 18 pts and high (>2.54) in 13 pts. Mean (sd) total (diet plus binder) oral calcium intake (mg/d) was 1996 mg/d (1020); 16 pts (38%) had an excessive oral total calcium intake (> 2000 mg/d). Calcium intake and serum calcium were poorly correlated (spearman rank method) r=0.14, p=0.4 Median calcium intakes were similar in those with normal (1990 mg/d), high normal (1926 mg/d) and high calcium groups (1713 mg/d), p=0.73 (Kruskal-Wallis), p=0.29 (linear test for trend). The n (%) of subjects with an excessive oral calcium intake by S.Ca ALB COR were: 2.1– 2.37mmol/l: 4 pts (36%); 2.37-2.54 mmol/l: 7 pts (39%) and >2.54 mmol/l: 5 pts (39%). Similar results to the above were found using unadjusted serum calcium levels. Though limited by its modest sample size and inability to assess the extent of calcium absorption from the GI tract, our results suggest that serum calcium is not a useful surrogate measure of total oral calcium intake and may not accurately reflect the degree of calcium loading.
A37
37
39
% of Hospitalizations
INPATIENT USE OF ERYTHROPOIESIS STIMULATING AGENTS (ESA) AMONG COMMERCIALLY-INSURED DIALYSIS PATIENTS 1Donald Brophy, 2Carolyn Harley, 2Benjamin Chastek, 3 Gregory Daniel, 3Brian McNeeley, 4Matthew Gitlin, 4Tracy J Mayne. 1 Virginia Commonwealth Univ, Richmond, VA; 2i3 Innovus, Eden Prairie, MN; 3HealthCore, Inc, Wilmington, DE, 4Amgen Inc., Thousand Oaks, CA. There is evidence that dialysis patients return from hospitalizations with low hemoglobin levels (Yaqub, 2001; Turenne 2007). Dialysis patients receive outpatient ESAs and one possible factor may be that patients do not receive ESA therapy during hospitalization. This study descriptively evaluates inpatient ESA use from 2004 - 2005 among privately insured dialysis patients. This was a cross-sectional retrospective analysis of claims from two large US managed care organizations (MCO) covering a combined 20 million lives over two years. ESRD patients were identified by ≥1 ESRDspecific claim in the inpatient setting, or ≥3 dialysis-related claims on separate days during each 12-month period. We examined patient demographics and hospitalization characteristics, including the percent of patients receiving ESAs during hospitalization by length of stay (LOS). Patient demographics were similar across years and MCOs. The mean (+SD) number of hospitalizations over both years were ~1.1 (+1.3) for MCO#1 and ~1.6 (+ 1.7) for MCO#2. Table 1:% of hospitalizations with ESA use by LOS 40% 30% 20% 10% 0%
MCO #2 MCO #1 (Averaged across both years)
≤7
8-14 15 – 21 > 21 Length of Stay (days) As shown, ESA use was low, but increased with LOS. Given the low rate of ESA use, patients may be at risk for falling Hb levels during and post hospitalization discharge. Further analysis is warranted to investigate factors associated with ESA use and non-use in the inpatient setting.
38
TESTICULAR ANGINA ON DIALYSIS: A NOVEL PRESENTATION WHILE ESTA BLISHING DRY WEIGHT, Buffington, Mary; Sequeira, Adrian; Isaac, Prasanna; Bahta, Elias Establishment of dry weight is limited by the development of cramps or hypotension during dialysis. We present a case of testicular angina that developed while trying to attain dry weight. The patient is a 68 year old male with hypertension, type two diabetes mellitus and end-stage renal disease on hemodialysis. His surgical history is significant for ischemic colitis with sigmoid resection and abdominal aortic aneurysm repair. He presented initially with volume overload and while attempting to readjust his dry weight on dialysis, he complained of testicular pain occurring peculiarly toward the end of his dialysis session. A few months earlier, he was treated for possible epididymitis and although his symptoms had initially improved with antibiotics they recurred over the last month. He denied any history of sexually transmitted diseases. On examination, he had atrophic and very tender testes particularly on the right although externally the scrotum appeared normal. No swelling, hydrocele, or prostatic tenderness was noted. A CAT scan revealed severe atherosclerotic disease involving nearly every vessel of the pelvis including the spermatic cord vessels. Doppler evaluation and color-flow analysis then showed no flow to either testicle. He underwent bilateral simple orchiectomy for testicular angina with testicular atrophy. Pathology of the resected testes showed extensive atrophy with fibrous parenchyma suggestive of chronic ischemia with evidence of chronic epididymitis. The two commonest mechanisms involved with scrotal pain include decreased blood supply and infection. In a unique presentation, the patient had testicular angina toward the end of dialysis when his blood pressure and intravascular volume were relatively low. This may have aggravated the underlying ischemia. It is believed that the chronic ischemia may have predisposed to a smoldering epididymitis.
40
CALCIFIC UREMIC ARTERIOLOPATHY (CUA) SUCCESSFULLY TREATED WITH INTRAVENOUS SODIUM THIOSULPHATE 1
2
3
Ion D Bucaloiu MD , Evan Norfold MD , Nektarios Lountzis MD , Fred O Miller MD3, Dirk Elston MD3. 1 Department of Internal Medicine, Geisinger Medical Center, Danville, PA. 2 Department of Nephrology, Geisinger Medical Center, Danville, PA. 3 Department of Dermatology, Geisinger Medical Center, Danville, PA.
A 45-year-old African American female with end stage renal disease on chronic peritoneal dialysis developed painful indurated plaques on her buttocks and breasts with subsequent ulceration. Skin biopsy revealed focal intralobular subcutaneous capillary microvascular thrombosis with focal acute inflammation, and rare subtle foci of staining with a von Kossa stain, suspicious for calciphylaxis. Laboratory data revealed a serum calcium and phosphorus product of 45 and a parathyroid hormone level of 581 pg/mL. Despite treatment with cinacalcet and ongoing wound care her secondary hyperparathyroidism and wounds continued to worsen. A subtotal parathyroidectomy significantly improved her PTH levels (886 pg/mL to 107 pg/mL), but her wounds continued to progress and her clinical course was complicated by several episodes of hypocalcemia and bacterial superinfection requiring hospital admission for intravenous calcium and antibiotics. Treatment with intravenous sodium thiosulphate three times weekly was initiated with a dramatic response. Pain resolved after three to four days. Ulcers on the buttocks had healed completely after 6 weeks and those of the breasts were approximately 60% healed (figures). CUA is a severe disease resulting in necrosis of the skin and subcutaneous tissue, leading to extensive wounds, severe pain and high mortality. This case highlights and expands on the mounting evidence of intravenous sodium thiosulphate as a successful treatment for calciphylaxis.
Relationship of calcium intake with serum calcium level. Ms. Fiona Byrne, Dr Sinead Kinsella and Dr JA Eustace. Cork University Hospital, Cork, Ireland We conducted the following prospective observational study on 42 (25 male, 17 female) stable, non-diabetic maintenance hemodialysis patients (pts) to quantify the relationship of oral calcium intake with serum calcium levels. Subjects kept a detailed food diary for 1 week followed by a detailed interview with an experienced renal dietician. Nutrient intake was calculated using WISP v2.0 (Tinuviel Software) Albumin adjusted serum calcium levels were measured pre dialysis on days 1 and 7. Mean (sd) serum albumin, day 7 uncorrected serum calcium (S. Ca), and day 7 albumin corrected serum calcium (S.Ca ALB COR ) were: 35.7 g/dl (2.9), 2.37 mmol/l (0.21) and 2.46 mmol/L (0.2). The day 1 and day 7 serum calcium levels were very similar (mean difference 0.004 mmol/l). S.Ca ALB COR was low (<2.1 mmol/l) in 2 pts, normal (2.1-2.37) in 9 pts, high normal (2.37-2.54) in 18 pts and high (>2.54) in 13 pts. Mean (sd) total (diet plus binder) oral calcium intake (mg/d) was 1996 mg/d (1020); 16 pts (38%) had an excessive oral total calcium intake (> 2000 mg/d). Calcium intake and serum calcium were poorly correlated (spearman rank method) r=0.14, p=0.4 Median calcium intakes were similar in those with normal (1990 mg/d), high normal (1926 mg/d) and high calcium groups (1713 mg/d), p=0.73 (Kruskal-Wallis), p=0.29 (linear test for trend). The n (%) of subjects with an excessive oral calcium intake by S.Ca ALB COR were: 2.1– 2.37mmol/l: 4 pts (36%); 2.37-2.54 mmol/l: 7 pts (39%) and >2.54 mmol/l: 5 pts (39%). Similar results to the above were found using unadjusted serum calcium levels. Though limited by its modest sample size and inability to assess the extent of calcium absorption from the GI tract, our results suggest that serum calcium is not a useful surrogate measure of total oral calcium intake and may not accurately reflect the degree of calcium loading.